Elder Trip Application-Denver March 2024 Powwow

Elder Trip Application-Denver March 2024 Powwow
ELDER TRIP 2024 – PARTICIPANT APPLICATION
100 QUALIFYING TRIBAL ELDERS will be selected to travel to Denver March Powwow. Selections will be
announced on March 1st.
DEPART: Wednesday,March 13th
RETURN: Sunday, March 17th

DEADLINE TO SUBMIT APPLICATION IS FRIDAY, February 29, 2024

TO BE CONSIDERED, YOUR APPLICATION MUST BE SUBMITTED TO THE DESIGNATED CONTACT—WE WILL NOT BE RESPONSIBLE FOR APPLICATIONS SENT TO ANY OTHER CONTACT.
APPLICANT INFORMATION
Name*

First NameMiddle NameLast Name
Tribal ID# : 2801A * .
Date of Birth*

MonthDayYear
Date
Community*
Address*

Address

Street Address Line 2

CityState / Province

Zip
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone *

Area CodePhone Number
THE TRIP
I plan to ride the chartered bus.*

YesNo
I plan to drive my personal vehicle.*

YesNo
I have been on an out of state Elders Trip before.*

YesNo
If yes, please indicate the year(s) you attended.

2013201420152016201820192023
I require the use of one or more medications.
I require the use of special medical equipment.
Please specify
I request the following person as my roommate
T-shirt Size*

SMLXL2XL3XL4XL
FAMILY CONTACT

(In case of an emergency while on this trip, this person is to be contacted)
Name*

First NameMiddle NameLast Name
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Name

First NameMiddle NameLast Name
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Release of Liability
My participation in this activity is voluntary and I am acting under my own free will. I attest that I do not have any medical ailments or mental disabilities that would affect my full participation in this activity and I assume any risks involved in taking this trip. I understand that if I have physical restrictions that prevent me from riding the bus, I will be able to join in the hotel/meal amenities being provided, if I provide my own transportation. I release the Cheyenne and Arapaho Tribes from any and all claims and causes of action that I may have for personal injury or property theft/damage that may arise from my participation in this trip. I further agree to represent the Cheyenne and Arapaho Tribes in a respectable manner during this time and abide by all rules as set forth.
Participant Signature

Clear
Date

MonthDayYear
Date
WE ENCOURAGE YOU TO CALL AND FOLLOW UP ON YOUR FAXED APPLICATION!
Cheyenne & Arapaho Tribes | Executive Office

Contact: Marshall Medicine Bear | Phone (405) 422-7551 Email:AnnualElderTrip@cheyenneandarapaho-nsn.gov| Fax (405) 422-8296
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Elder Trip Application-Denver March 2024 Powwow

APPLICANT INFORMATION

THE TRIP

FAMILY CONTACT

Release of Liability

WE ENCOURAGE YOU TO CALL AND FOLLOW UP ON YOUR FAXED APPLICATION!